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Salary: USD 78,000 - 103,000 / annual
Akido Labs is an AI-native healthcare provider serving 500K+ patients across California, Rhode Island, and New York, offering primary and specialty care in 26 specialties. Founded in 2015 (YC W15) and recently raised $60M Series B, Akido combines cutting-edge AI technology with a nationwide medical network to address physician shortages and expand access to exceptional healthcare.
The Clinical Review Nurse – Complex Case Management and Prior Authorization role sits within the Utilization Management (UM) department and is responsible for reviewing and processing prior authorization requests while supporting complex case management for high-risk members. This position works closely with providers, Medical Directors, and operational teams to ensure timely and accurate authorization determinations in a California managed care environment.
Key responsibilities include:
- Reviewing and processing prior authorizations for outpatient services, procedures, diagnostic testing, specialty referrals, DME, and ancillary services
- Evaluating requests using MCG guidelines and health plan criteria and policies
- Reviewing medical records and supporting clinical documentation to ensure completeness, accuracy, and medical necessity
- Identifying missing or insufficient documentation and coordinating with providers for additional information
- Leading interdisciplinary care management for high-risk, medically and psychosocially complex populations to reduce readmission rates and key utilization metrics
- Ensuring all clinical determinations are properly documented in EZCap system
- Maintaining compliance with DMHC prior authorization requirements, CMS guidelines, health plan delegation standards, turnaround times, and notification requirements
- Communicating with physicians, medical groups, facilities, and ancillary providers to obtain clinical information and provide authorization status updates
- Identifying cases requiring clinical review and preparing clinical summaries for Medical Director determination
- Routing cases requiring denial appropriately to the Medical Director
- Conducting comprehensive assessments and contributing to development of patient-centered care plans in collaboration with Medical Director
- Performing monthly care management outreach, medication review, and specialist/community resource coordination
- Collaborating with UM Coordinators, Claims, Eligibility, and Operations teams
Requirements:
- Active California RN license (required)
- 3–5+ years of current clinical UM review experience
- Experience with prior authorization in managed care or delegated environment
- Experience with complex case management
- Knowledge of MCG criteria, medical necessity review, and prior authorization workflows
- Knowledge of California managed care regulations (DMHC/CMS)
- Strong clinical assessment skills and attention to detail
- Effective written and verbal communication
- Ability to manage competing priorities in a fast-paced environment
- Experience with EZCap (preferred)
- Experience in a delegated MSO or health plan environment (preferred)
- Certified Case Manager (CCM) certification (preferred)
